Chapter Contents

Introduction

Theories of social class and social stratification suggest a variety of bases for social hierarchies. On an empirical basis, different
indicators of socioeconomic status each show similar graded relationships with health despite the fact that they are only moderately
interrelated. Education, income and occupation provide specific resources. In addition, they locate individuals in relevant social
hierarchies where relative position may itself be a risk or protective factor. The MacArthur Network on SES & Health developed a
measure of subjective social status to try to capture individuals' sense of their place in the social ladder which takes into account
standing on multiple dimensions of socioeconomic status and social position.

Measurement

The MacArthur Scale of Subjective Social Status was developed to capture the common sense of social status across the SES indicators.
In an easy pictorial format, it presents a "social ladder" and asks individuals to place an "X" on the rung on which
they feel they stand. There are two versions of the ladder, one linked to traditional SES indicators
(SES ladder) and the second linked to standing in one's community
(community ladder). The difference between these two ladders may be of
particular interest in poorer communities in which individuals may not be high on the SES ladder in terms of income, occupation,
or education, but may have high standing within their social groups such as a religious or local community. Insofar social standing
has beneficial effects on biological processes related to health, standing on the community ladder may be as important as standing
on the SES ladder. Ideally, it would be best to use both ladders (and, if so, one should have participants complete the community
ladder first so responses to it aren't keyed to the SES indicators which are described for the SES ladder). If the research is
investigating traditional SES, it will be of particular importance to use the SES ladder to be able to make comparisons between
objective and subjective SES.

Relationship to SES

Relationship of objective indicators of SES to the SES ladder.

Several studies have examined predictors of the SES ladder. We would expect there to be a significant but not perfect relationship
of traditional indicators of SES (e.g., measures of education, individual and family income, occupation and wealth) and subjective
social status. Ladder rankings should reflect but not be redundant with the objective indicators. The SES ladder provides a summative
measure of social status. Individuals are asked to summate across those indicators and each may assign different weights to the various
components of SES. In addition, people may have a deeper understanding of the meaning of their standing on a given aspect of SES. Thus
just like self-rated health predicts mortality even when adjusted for all known objective risk factors (Idler and Benyamini, 1997),
subjective social status may be a "value added" of the individual's evaluation of their status and the actual implications of the objective
indicators. For example, measures of educational attainment treat "high school graduation" as the same value whether one graduated from
an elite prep school or an inner city high school, and "college graduation" the same for graduation from a top-ranked college or a
diploma-mill. Yet the life chances of these graduates are quite different and are likely to be more sensitively captured by the ladder
ranking than by the rather crude educational levels.

Whitehall II Study of British civil servants SES ladder scores are predicted by employment grade, education, household and personal
income, household wealth, satisfaction with standard of living, and feelings of financial security. Childhood SES is also related to
ladder ranking. Education and income are more strongly related to objective SES (as assessed by occupational grade) while a feeling of
financial security is more strongly related to subjective SES as assessed by the SES ladder. Childhood SES and wealth are almost equally
related to objective and subjective SES. Singh-Manoux, Marmot, Adler, (2005) suggest that the stronger association between subjective SES
and the feeling of financial security in this middle-aged cohort suggests that subjective SES provides a better assessment of a person's
future prospects, opportunities, and resources than objective SES.

In the US, predictors differ for White and Black participants in the Coronary Artery Risk Development in Young Adults (CARDIA).
Financial security, material deprivation and education are significant predictors of ranking on the SES ladder for both white and
black participants. However, household income and wealth predict subjective social status for Whites in CARDIA but not for Blacks
(Adler, Singh-Manoux, Schwartz, Stewart, Matthews & Marmot, 2008). Unlike the results in Whitehall II where psychosocial
factors were not related to ladder scores, in CARDIA ladder rankings were associated with optimism for both groups, and with control
in Whites and mental health for Blacks.

Qualitative investigation of criteria used for SES ladder rankings. In an exploratory qualitative study done for the
MacArthur Network, Snibbe, Stewart & Adler (in preparation 2007) explored the criteria people say they use to decide their position
on the SES and Community ladders. In an interview, 60 participants in the CARDIA study narrated how they ranked themselves on the SES ladder.

The most frequently mentioned source of subjective social status on the SES ladder was material wealth, mentioned by over 90% of
participants (however about a fifth of participants also rejected materialism). The next most frequently mentioned sources of subjective
social status were occupation (72%) and education (62%). Almost a quarter of participants indicated using their spirituality or ethical
values, and a fifth of the sample used the extent to which they give to others and their health as considerations when determining
ranking on the SES ladder. It is not surprising that respondents thought about financial, educational and occupational standing in
answering the question of where they stand on the SES ladder since these are the dimensions the scale specifically mentions. The categories
of ethics/spirituality, health and social responsibility or altruism ("giving") which were spontaneously generated have more to do with
personal qualities and a subjective sense of self-worth than objective markers of status. As indicated such factors may play a not
insignificant role in subjective social status.

Definition of "community" and criteria used for Community ladder rankings. In addition to the SES ladder a second ladder
asks people to indicate how they stand in their communities. No criteria are given either for the nature of community or the dimensions
of status to be used. The qualitative analyses revealed that the majority of participants defined community as their neighborhood (57%).
Significantly more African American participants (80%) than European American participants (33.33%) used this definition. The next most
popular definition of community was city or town (37%), followed by religious groups (22%), social supporters (20%), workplace (18%),
family (18%), friends (12%), people who share their interests (12%), their region (12%), and, finally the nation or world (10%). Additionally,
almost half of the participants generated idiosyncratic definitions of community that did not fit in any one category. There were no gender or
race differences in mentions of categories other than "neighborhood."

Unlike their responses to the SES ladder, participants relied little on their wealth (25%), education (7%), or occupation (22%) when
deciding where to place themselves on the Community ladder. Instead, they most frequently mentioned the everyday ways they give to
others—as volunteers, as donors, as good citizens, and as good neighbors with close to 87% mentioning participation in giving
activities. A second frequently mentioned source of subjective social status was how well-liked or respected they are by others (52%),
followed closely by admissions of feeling as if they do not give enough to their community (50%). (Interestingly, "being respected"
was a high frequency content code for the Community ladder but not for the SES ladder.) The remaining categories, in order of frequency,
were giving as a leader (37%), giving as a parent (32%), and 12% rejected materialism as contributing to Community subjective social status.
Health was not mentioned as a source of subjective social status on the Community ladder as it had been on the SES ladder.

Analyses of the Community ladder narratives revealed that more African American (36.67%) than European American (13.33%) participants
mentioned materials / money, and conversely, more European American (13.33%) than African American (0.00%) participants mentioned education.
Finally, a trend-level effect showed that more African Americans (33.33%) mentioned spirituality and ethics than did European Americans.
The best predictor of the Community ladder rankings was SES ladder ranking, which alone explained 33% of the variance with two of the
"giving" variables—giving as a parent and complaining of not being active enough—increasing the explained variance to 47%.

The qualitative study gives some hints about answers to important questions such as how people define community and what dimensions
they use in placing themselves on the Community ladder.

Relationship of the SES and Community ladders. To date relatively little research has been done using the Community ladder. In
the few studies where both ladders have been used they have been found to be correlated. Goldman, Cornman and Chang (2006) in a Taiwanese
sample showed that although the two ladders were highly correlated (with a Pearson correlation, equal to the Spearman rank correlation of
0.78), their sample of middle-aged and older Taiwanese residents ranked their social position within their community an average of 0.4-rung
higher than they ranked their position within Taiwan. Analyses of ladder rankings from CARDIA at the Year l5 exam show the two ladders were
correlated 0.54. In this group of over 3,000 participants African-American men and women ranked themselves an average of 0.92 rungs higher
on the Community than SES ladders whereas European-American men and women demonstrated more similar SES and Community ratings, 0.19 and
0.34 differences respectively (personal communication J.Schwartz).

Relationship to Health

A growing literature is emerging on the linkage between subjective socioeconomic status and health. The SES ladder has been
used in a number of studies with populations that range from British civil servants (Singh-Manoux, Adler & Marmot, 2003;
Singh-Manoux, Marmot & Adler, 2005), to pregnant women from four different US ethnic groups (Ostrove, Adler, Kuppermann
& Washington, 2000), to adolescents in the US Midwest (Goodman, Adler, Kawachi, Frazier, Huang & Colditz, 2001; Goodman,
Adler, Daniels, Morrison, Slap & Dolan, 2003; Goodman, McEwen, Dolan, Schafer-Kalkhoff & Adler, 2005), to elderly residents
of Taiwan (Hu, Adler, Goldman, Weinstein & Seeman, 2005), to residents of small towns in three provinces in China (Yip &
Adler, 2005), to low-income rural Mexicans (Jamison, J., Fernald, L., Burke, H., & Adler, N.E., July 2005), to older retired
residents of Britain (Wright & Steptoe, 2005) and representative samples of individuals in the United States (Operario, Adler
& Williams, 2004), and Hungary (Kopp, Skrabski, Rethelyi, Kawachi & Adler, 2004; Kopp, Skrabski, Kawachi & Adler, 2005).
The results have shown that subjective status is related to a range of health indicators, including poor self-rated health, higher
mortality, depression, cardiovascular risk, diabetes and respiratory illness. For example, in the Whitehall II Studies of British
civil servants higher SES ladder scores were associated for men and women with lower prevalence of angina, diabetes, GHQ depression,
and better perceived general health. Higher SES ladder scores were also associated with lower prevalence for men of respiratory problems.

In several of the studies subjective status showed a stronger relationship with the health indicators than did objective status
and remained significant when objective indicators of SES were entered simultaneously into analytic models. In one study, for example,
the ladder metric did a better job of predicting heart rate, body fat distribution, and cortisol responses to stress than did objective
SES measures ( Adler, Epel, Castellazzo, & Ickovics, 2000). Other studies show that the relationship between the ladder and health
outcomes remains robust even when researchers statistically control for objective SES indicators (Ostrove, Adler, Kuppermann, &
Washington, 2000; Singh-Manoux, Adler, & Marmot, 2003). In the Whitehall study of British civil servants, subjective social status
predicted change in health status even controlling for occupational grade (Singh-Manoux, Marmot, Adler, 2005). Wright & Steptoe
(2005) showed that the impact of subjective social status on the cortisol response to awakening was independent of age, body mass index,
smoking, time of waking, educational qualifications, financial strain, number of chronic illnesses and medication count in an older
retired sample. They note that in older adults, subjective social status may be particularly useful in providing an aggregate estimate
of lifetime social experience not so effectively captured by objective markers of SES.

Differences by race/ethnicity. Although the ladder has been used with a variety of samples, there is some evidence that it
may not operate in the same way for all groups. Ostrove, etal (2000) found that subjective SES was significantly related to self-rated
health among four groups of women (White, Chinese American, African American and Latina). Subjective social status was a significant
predictor of self-rated health after the effects of objective indicators were accounted for among White and Chinese American women,
however, among African American and Latina women, household income was the only significant predictor of self-rated health. After
accounting for the effects of subjective social status on health, objective indicators made no additional contribution to explaining
health among White and Chinese American women however household income continued to predict health after accounting for subjective social
status among Latina and African American women.

What the ladders are capturing. The research to date provides evidence that the ladder ratings are picking up something
meaningful for health, but it is not clear what these ratings reflect. One concern, of course, is whether these ratings are simply
reflections of other variables with which they are confounded. There are two plausible types of variables which could account for
an association of ladder scores and health outcomes.

One potential confounder is response bias. It could be that individuals who rate themselves high on the ladder also report better
health because of a response set or social desirability. If so, we would expect to find associations of ladder rankings with self-rated
variables, such as global health, but not with variables measured independently, such as physiological functioning or mortality. Ladder
scores show significant associations with both types of variables suggesting that response bias alone cannot account for the association
of subjective social status and health. In addition Singh-Manoux etal (2005) showed that ladder rankings predicted global health 3 years
later, controlling for global health status as assessed at initial measurement. Since this controls for the shared variance of subjective
social status and self-rated global health, the prediction of subsequent global health ratings would be independent of any shared
association due to response bias or other confounders.

A second potential confounder is negative affect. Individuals who are depressed or who experience negative affect may both rate
themselves low on the ladder and rate their health as poor. There is a relationship between ladder scores and negative affect and
depression. However, it appears that this is more likely to be due to the influence of low subjective status on affect than vice
verse. As above, findings from studies with outcomes that are not self-report and the longitudinal study suggest that negative affect
is not a major confounder. In addition, several studies demonstrate a significant association of ladder rankings with self-rated
health even when negative affect is controlled for. Operario, etal (2000) found that negative affect was not only related to
subjective SES but also to objective SES indicators. Moreover, when adjusted for negative affect, both objective and subjective SES
showed somewhat weaker associations with global health. This is consistent with a mediational model in which both objective and
subjective status affect health in part by increasing negative affect.

Given that the SES ladder shows robust associations with health which are not simply due to confounding with response style or
negative affect, it is important to know what the ladder rankings are capturing. Below we discuss quantitative and qualitative approaches
to that question.

Network Usage

The SES ladder has become an integral measure in network research. We receive many requests to use the ladder in non-network research.
Nancy Adler has consulted on the majority of studies noted in this review. New versions of the ladders, for example, for research with
adolescents, and Spanish and Hungarian translation have been developed in the last few years.